1. Developing e-health solutions to improve patient safety in primary care Report on an NPSA-funded project Professor Tony Avery University of Nottingham

2. Background There are concerns about patient safety in primary care in terms of: There are concerns about patient safety in primary care in terms of: Prescribing errors Prescribing errors Failure to complete intended actions such as patient referrals and medication monitoring Failure to complete intended actions such as patient referrals and medication monitoring Failure to respond to abnormal results or advice from other professionals Failure to respond to abnormal results or advice from other professionals Safe and effective communication of information between GPs and patients and professionals in secondary care and community pharmacy Safe and effective communication of information between GPs and patients and professionals in secondary care and community pharmacy

3. Potential role of computer systems Computers have considerable potential to help GPs to practise safely in terms of providing: Computers have considerable potential to help GPs to practise safely in terms of providing: –Accurate information on patients and drugs at the point of decision-making –Effective decision support –Intelligent hazard alerts for cautions, contraindications, drug interactions and allergies –Help with timely and appropriate monitoring –Help with error trapping –Reporting on patients at risk

8. Why the need for a project? While computer systems have considerable potential some problems have been highlighted: While computer systems have considerable potential some problems have been highlighted: –GPs and practice staff may not know how to make best use of their systems and may not use important safety features –GPs may override hazard alerts –Computer systems may not contain all the safety features that are desirable

9. Objectives of the project To identify the most important safety issues regarding GP computer systems To identify the most important safety issues regarding GP computer systems To assess GP computer systems in terms of these safety features To assess GP computer systems in terms of these safety features To determine GPs knowledge, use and training needs in relation to computerised safety features To determine GPs knowledge, use and training needs in relation to computerised safety features To work with stakeholders to produce specifications for GP computer suppliers and for training practice staff To work with stakeholders to produce specifications for GP computer suppliers and for training practice staff

10. Identifying the most important safety issues Methods used: Methods used: –Stakeholder interviews –Two-round Delphi

11. Stakeholder interviews GPs GPs Computer system suppliers Computer system suppliers Drug database suppliers Drug database suppliers SCHIN SCHIN RCGP RCGP DoH DoH NHSIA NHSIA Design Authority Design Authority MDU and MPS MDU and MPS Patients representative Patients representative Experts in health informatics Experts in health informatics

12. The Delphi exercise 21 participants 21 participants Presented with 55 statements Presented with 55 statements 33 statements ranked as important or very important by over 90% of respondents 33 statements ranked as important or very important by over 90% of respondents

13. Key issues from Delphi and stakeholder interviews Importance of computerised alerts Importance of computerised alerts The need to ensure that users record data so that functionality is available when required The need to ensure that users record data so that functionality is available when required The need for a drug dictionary for NHS primary care The need for a drug dictionary for NHS primary care The need for drug ontologies that provide sensible alerts and decision support The need for drug ontologies that provide sensible alerts and decision support Avoiding spurious alerts Avoiding spurious alerts Making it difficult to override critical alerts and to have audit trails Making it difficult to override critical alerts and to have audit trails Effective computer-user interface: ensuring that account is taken of human ergonomics Effective computer-user interface: ensuring that account is taken of human ergonomics Support for safe repeat prescribing Support for safe repeat prescribing Importance of call and recall: ensuring that intended actions such as patient referrals and medication monitoring are completed Importance of call and recall: ensuring that intended actions such as patient referrals and medication monitoring are completed Need to be able to run safety reports Need to be able to run safety reports

14. Assessing GP computer systems From the results of the Delphi we have developed a series of vignettes/test cases From the results of the Delphi we have developed a series of vignettes/test cases These have been used on the main GP computer systems with dummy patients These have been used on the main GP computer systems with dummy patients Suppliers were asked to comment on the results Suppliers were asked to comment on the results Results available on www.bmj.com BMJ 2004;328:1171-1172 Results available on www.bmj.com BMJ 2004;328:1171-1172 www.bmj.com

15. Key points from assessment of GP computer systems There are a lot of good features, but we have detected some problems: There are a lot of good features, but we have detected some problems: –Lack of alerts in relation to contraindications –Spurious alerts –Failures of drug allergy warnings –Risks of prescribing drugs with similar names –Lack of warning for methotrexate –Hidden alerts –It is easy to override most alerts –Lack of audit trials

28. Determining GPs knowledge, use and training needs We have undertaken interviews with GPs: We have undertaken interviews with GPs: –There was a strong sense that they have come to rely on their computers to provide alerts We have developed a questionnaire that has been sent to GPs in two sites in England (387 responses; 64% response rate) We have developed a questionnaire that has been sent to GPs in two sites in England (387 responses; 64% response rate)

29. Key findings from the GP questionnaire (1) The following are regarded as important by >90% of GPs The following are regarded as important by >90% of GPs –computerised alerts Allergy alerts (99%) Allergy alerts (99%) Interaction alerts (99%) Interaction alerts (99%) Contraindication alerts (99%) Contraindication alerts (99%) –Need to make it more difficult to override critical alerts –Systems for recall for patient monitoring

30. Key findings from GP questionnaire (2) GPs are not fully aware of the safety features on their computer systems, e.g. a third of users of a system that doesnt have contraindication alerts thought that the system did have these alerts! GPs are not fully aware of the safety features on their computer systems, e.g. a third of users of a system that doesnt have contraindication alerts thought that the system did have these alerts! Only a minority have had training on the use of safety features on their computers Only a minority have had training on the use of safety features on their computers The preferred method for learning more about the use of safety features is hands-on learning with tuition (either one-to-one or in a group setting) The preferred method for learning more about the use of safety features is hands-on learning with tuition (either one-to-one or in a group setting)

31. Stakeholders views on how to make improvements to systems System suppliers are willing to make changes provided these are sensible and in keeping with GP opinion System suppliers are willing to make changes provided these are sensible and in keeping with GP opinion Suppliers acknowledge that change is more likely to take place if this is made mandatory rather than voluntary Suppliers acknowledge that change is more likely to take place if this is made mandatory rather than voluntary Working through the National Programme for IT in the NHS is likely to be the best way of ensuring change Working through the National Programme for IT in the NHS is likely to be the best way of ensuring change

32. Suggestions for improvement in the short-term Act to close the loophole in the recording of allergy alerts Act to close the loophole in the recording of allergy alerts Define the most important hazard alerts, ensure these are available on all systems and that they cannot easily be overridden Define the most important hazard alerts, ensure these are available on all systems and that they cannot easily be overridden Ensure that system suppliers make full use of ontologies available to them, e.g. for contraindication alerts Ensure that system suppliers make full use of ontologies available to them, e.g. for contraindication alerts Develop a computerised query set for interrogating GP computer systems to identify hazards Develop a computerised query set for interrogating GP computer systems to identify hazards Develop a training package to help practices make best use of the safety features of their clinical computer systems Develop a training package to help practices make best use of the safety features of their clinical computer systems

33. Suggestions for improvement in the longer-term Introduce a drug dictionary for the NHS Introduce a drug dictionary for the NHS Evaluate existing ontologies to determine whether these are fit-for-purpose or whether alternatives need to be developed Evaluate existing ontologies to determine whether these are fit-for-purpose or whether alternatives need to be developed Ensure that systems are designed to make it easy to do the right thing Ensure that systems are designed to make it easy to do the right thing Ensure that the design of alert messages take account of research indicating best practice Ensure that the design of alert messages take account of research indicating best practice Ensure that health professionals are properly trained to make best use their systems Ensure that health professionals are properly trained to make best use their systems Work to develop safety culture in primary care Work to develop safety culture in primary care

34. Summary GP computer systems already have a number of important safety features GP computer systems already have a number of important safety features There are problems in that There are problems in that –GPs have come to rely on hazard alerts when they are not full-proof –GPs do not know how to make best use of safety features on their systems There are a number of solutions that could either There are a number of solutions that could either –Help to improve the safety features of GP computer systems –Help to improve the abilities of healthcare professionals to use these safety features